Nursing malpractice: the importance of documentation, or saved by the pen!
Documentation is an elemental to nursing as wound care and vital sign assessment. This article examines the reasons and techniques for accurate and complete documentation in a medical record. Several examples of nursing malpractice involving improper documentation are described. Abbreviations, flow sheets, incident reports, late entries, errors and content are included in the discussion presented.
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D006801:Humans; D008318:Malpractice / Q000331:legislation & jurisprudence*; D009730:Nursing Assessment / Q000592:standards*; D009737:Nursing Records / Q000592:standards*; D012308:Risk Management; D016312:Treatment Refusal